Clinically Integrated Networks (CINs) are evolving quickly across the country in response to changing reimbursement trends and the move to value-based payments.
Clinically Integrated Networks (CINs) are evolving quickly across the country in response to changing reimbursement trends and the move to value-based payments. Estimates indicate more than 500 CINs are in operation in the country today.
In most markets, single healthcare systems have formed independent CINs in an effort to more formally align independent and employed physicians in the region. In certain markets, we are starting to see the development of Super CINs or Population Health Alliances.
The formation of Super CINs and Alliances is motivated by the perceived need to reach larger populations and to form more comprehensive delivery networks, in many cases fueled by increased competition within the marketplace. The main goals of most Super CIN/Alliance structures is to expand network offerings and services through direct-to-employer products and to effectively pool resources to build robust population health infrastructures.
Independent systems believe they can achieve greater benefits through joint collaboration than on their own and trust that they will ultimately be better positioned for value-based care.
Alliances are formed by integrating a number of healthcare institutions under one CIN structure, in which hospitals remain independent while pooling clinical, technological, and strategic resources. This includes employed physicians and community physicians within local networks.
Super CINs are the product of multiple CINs under a single superstructure. Super CINs and alliances allow smaller systems, hospitals, and physician organizations to leverage infrastructure costs, management and governance oversight, care management protocols, population health management capabilities, as well as population financial risk while still retaining their independence.
Structuring and effectively managing Super CINs formed between competing healthcare entities is a complex undertaking that should not be pursued without clear and deliberate discussion among the respective parties. There are a number of strategic, operational, and tactical components that need to be evaluated to determine how systems can work together and what challenges may be encountered.
Eight components to evaluate before forming a CIN
1. Leadership and governance. Do the management and physician leaders of each organization understand and embrace the principles and cultural change requirements of forming a Super CIN/Alliance? Have goals and objectives been clearly identified and articulated? Can necessary cultural transformation be executed across the network to deliver on the value proposition? Are individual organizations willing to cede certain functions and/or decisions to the Super CIN?
2. Strategy, sustainability, and transformation. What strategies need to be developed to create a sustainable model? Is there market demand for the product offerings and will it disrupt existing relationships? What activities and services will be provided by the network, and what services will be retained by each individual entity? How can knowledge and expertise be harnessed across the network?
3. Network composition and access. How comprehensive and accessible is the acute, post-acute, allied provider, and facility network in meeting patient care needs? How accessible are these segments today, and what would change under the new superstructure?
4. Population health management capability. What services are required to support the network? What are the population health management and analytic capabilities of each organization? Does one entity have a greater depth of experience, knowledge, and infrastructure? How will the alliance support the integration and launch of value-based products, including network development and management, care management, claims adjudication, risk management and compliance?
5. Clinical care models and coordination. What clinical care models are in place to manage high cost, chronic disease patient groups? What are the gaps and optimal approaches to integrate care to gain efficiencies across the network? Can existing programs be leveraged and re-tooled to support a larger population base?
6. Quality, value and transparency. What quality metrics are being measured and tracked at each organization? How are outcomes reported to providers to promote cost effective and high quality care? What reporting capabilities need to be developed? What will it take to aggregate meaningful data among these groups?
7. Financial management and reimbursement. What are the current financial incentives within the respective CINs? How will funds flow models be integrated across the network to incent and reward providers for improved health outcomes? How will risk be shared across the network versus borne by individual organizations?
8. Patient experience and activation. What communications, educational, and community support programs are needed to engage patients and improve compliance? How will these be shared across the network?
Other challenges to consider
The assessment of these critical components is essential and requires leadership to work collaboratively with institutions that are typically considered competitors under traditional reimbursement models.
Cultural differences between Super CIN/Alliance partners can also create governance challenges particularly as infrastructure expenses and shared savings distribution discussions and modeling are initiated.
It is a time of significant transition as providers and payers begin to work under the new healthcare paradigm and a lot remains unknown. In some markets, there is still significant resistance and uncertainty about value-based payment models and overall reform.
Regardless of the skepticism, the formation of Super CINs is gaining momentum across the country. Ascension Health and CHE Trinity Health announced the launch of their alliance in spring of 2014, creating one of the largest clinically integrated networks in the country uniting 27 hospitals, 12 physician organizations, and 5,000 physicians within Michigan.
Other examples of systems that have formed super CINs include: The Population Health Alliance of Oregon, a collaboration of seven health systems in Oregon and a major medical insurer; Greenville Health System; and Integrated Health Network, a seven health system collaboration including Froedtert Health, the Medical College of Wisconsin, Wheaton Franciscan Healthcare, Columbia St. Mary's, Ministry Health Care, and Agnesian HealthCare.
The impact on payer contracting and a shift to value-based payment models is among the greatest challenges for both the provider and insurance sectors. As healthcare providers begin to assume more risks for their populations, the roles and financial relationships become more interdependent and blurred. In markets where Super CINs are being formed, managed care contracting has become consolidated as plans begin to work with several institutions that were previously independent.
Timing the activities around care model and financial integration is pertinent to the design of Super CINs. Legal and regulatory issues around antitrust require that the organizations be clinically or financially integrated in order to jointly contract with payers.
Fully developing the payer strategy along with the timing and phases of integration of the Super CIN will support success. However, Super CINs that do not successfully integrate and remain unable to enter into joint agreements may be left with limited functionality.
Thoughtful planning and a well-constructed and executed vision will serve all entities well as they pursue further alignment in the ever changing healthcare landscape.
Tina Wardrop, MHA, MSSW, is a senior manager with The Camden Group. She has over 30 years of experience in the healthcare provider sector and has worked with a wide range of hospitals, healthcare systems, and independent and employed physician groups.
Susan Corneliuson, MHS, FACHE, is a senior manager with The Camden Group and has more than 14 years of healthcare management experience, with over 10 years of experience working with integrated healthcare delivery systems.